HomeMy WebLinkAboutSeptic Pumping Slip - 79 FULLER ROAD 5/25/2017 �
Commonwealth �
��^�Ml�]��[l\8/����.0 / ��/ Massachusetts
City/Town of
North
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided hare. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from thet,�qodate in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
onthe computer,
use only the tab
key tomove your *u*mvo
cursor-do not
North Andover
uoemo,mum ------ ----- ��-------------- ------------------
key. City/Town State Zip Code
VQ 2. System Owner:
Name
Ad�re'ss(if different from location)
City/Town state Zip Code
Tel^phon^Nvmuev
B. Pumping Record
1. Date ofPumping2. Quantity Pumped:
DateGallons
3. Component: Cesspool(s) 80' Septic Tank n Tight Tank Fl Grease Trap
`
[l Other(describe):
4. Effluent Effluen(Teo Filter present? U Yes F1 No If yes, was it cleaned? El Yes E:1 No
5. Observed condition ofcomponentpumped:
...........K�
-. _'-'—m P_m,-- By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball StBradford K8
Company
7. Location where contents were disposed:
2O so mill stbr�dford me
-Signature
-
Signature of Hauler Date
Si9natvm of R000|vinn Faoi|i�(vr oxw:x hwi|ity receipt), Date
(5fu,m4.d^^`11/12 System Pumping Record`Page 1of1